The patient underwent a laparoscopic converted to open right hemicolectomy with ileotransverse anastomosis. On laparoscopic exploration no signs of metastasis were noted and the intussusception of the ileum and cecum into the ascending colon was confirmed. On an account of the intussusception the mesentery was folded on itself and the ileocolic pedicle could not be isolated laparoscopically. The abdomen was subsequently opened and a lateral to medial approach was used to perform the ileocolectomy ensuring and adequate lymph node harvest. A side-to-side functional end-to-end anastomosis was constructed using a GIA stapler and the mesenteric defect was closed. The patient had return of bowel function on day 2 and was discharged. On outpatient follow up his anemia was resolving.
The pathology of the cecal mass was a 9.3 x 7.4 x 5.2 cm sessile tubulovillous adenoma with multiple scattered foci of high grade dysplasia and focal surface ulceration. There was no evidence of invasive neoplasia and the margins of the specimen were clear. Twelve lymph nodes were all negative for disease. The vermiform appendix showed a simple mucocele with xantho-granulomatous inflammation likely secondary to obstruction of the appendiceal orifice.
Discussion
Intussusception of the bowel occurs when a proximal portion of bowel (intussusceptum) telescopes into the lumen of the adjacent distal segment (intussuscipiens). Adult intussusception is quite rare compared to pediatric, accounting for only five percent of all cases. The pathophysiology and management of adult intussusception differs from pediatric intussusception due to the fact that a pathologic lesion is present in 70 to 90 percent of cases.1
Presentation of intussusception in adults can be acute, chronic, or silent, as in our patient. Adult patients generally present with symptoms of bowel obstruction including nausea, vomiting and abdominal pain. Guaiac positive stool, weight loss and a palpable abdominal mass can occur but are less common. 1 Our patient’s presentation with anemia, weight loss and fatigue without any abdominal symptoms is rather uncommon.
Diagnosis of intussusception uses a number of modalities including abdominal films, upper gastrointestinal series, barium enema, ultrasound, colonoscopy, CT and MRI imaging. Abdominal CT imaging is the most sensitive test with up to 78 percent accuracy.2 The classic finding is a target shaped mass. There is no standard algorithm for imaging and diagnosis of adult intussusception due to the non-specific presentation of the disease and numerous underlying types of pathology. Our patient’s initial presentation with anemia led to screening colonoscopy, which identified the mass. This was followed up with CT and MRI with a presumed diagnosis of colon cancer to further evaluate the mass as well as the possibility of metastatic disease. As imaging modalities improve idiopathic and asymptomatic intussusception are being more commonly diagnosed. Clinical evaluation is important in determining operative management. Patients with a palpable mass, obstructive symptoms, obstruction, gastrointestinal bleed or a lead point on CT scan warrant an operative exploration.3
The definitive treatment of intussusception in adults is surgical resection. The extent of resection is debated in the literature but often an oncologic resection is necessary due to the high incidence of carcinoma as the underlying cause.4 If there is a known benign lesion of the small bowel manual reduction can be performed with success.1 The mesentery is often carried forward and trapped between overlapping layers of bowel, which can lead to vascular compromise and ischemic necrosis.1 In our case, the trapping of the mesentery lead to difficult visualization and resection during the laparoscopic approach, which required conversion to an open procedure. An oncologic resection is the standard of care with a working diagnosis of cancer until proven otherwise. Our patient turned out to have a large high-grade tubulovillous adenoma in the cecum.
Intussusception is divided into four categories: enteric, colonic, ileocolic and ileocecal. Ileocolic occurs when the terminal ilium prolapses into the ascending colon whereas ileocecal occurs when the ileocecal valve acts as the lead point. In a review of 1048 cases, 64 percent percent of cases were found to be in the small bowel.1 Of cases in the small bowel 63 percent were benign, 14 percent were malignant and 23 percent were idiopathic. Intussusception of the large bowel accounted for 36 percent of total cases, of which 58 percent percent were malignant (e.g., adenocarcinoma, lymphoma, and lymphosarcoma), 29 percent were benign (e.g., lipoma, adenomatous polyps, endometriosis and prior anastomosis) and 13 percent were idiopathic.1
Benign causes of intussusception in the large bowel are less common. The lead point in our case was due to a large 9.3 cm tubulovillous polyp, which is quite rare. A few isolated case reports of intussusception secondary to tubulovillous adenomas are noted in the literature. In one case a 90-year-old male presented with symptoms of bowel obstruction for two weeks and a large friable mass protruding from his anus. CT scan revealed cecoanal intussusception and the patient underwent a subtotal colectomy for a 4 cm tubulovillous adenoma in the cecum.5 In a second case a 67-year-old male with one year of abdominal pain was found to have a 5.5 x 4.5 cm tumor in the cecum, which acted as the lead point for appendiceal intussusception. Pathology in this case revealed an underlying well-differentiated adenocarcinoma.6 Our case differs due to the total absence of abdominal symptoms. Although tubulovillous adenomas are benign lesions, their high risk of dedifferentiating into carcinoma should be weighed in the management as shown by the second case.
Conclusion
Most patients presenting with intussusception present with symptoms of bowel obstruction, but non-specific symptoms such as anemia or weight loss can be the only signs of disease. There is a high incidence of malignancy as the lead point in cases of large bowel intussusception and therefore a full metastatic workup should be considered. In these cases, resection rather than reduction is the treatment of choice. Oncologic principles should be followed with a minimum of 12 lymph nodes for staging. Laparoscopic surgery is desirable, but the complexity of these cases often leads to laparotomy for adequate resection.
Lessons Learned
Intussusception of the bowel in adults is rare. Due to the high risk of malignancy in large bowel intussusception a full metastatic workup should be pursed and an oncologic resection should be performed.
Authors
William C. Hope, MD
Thomas Jefferson University
Department of Surgery
Division of Colorectal Surgery
Philadelphia, PA 19107
Sumedh D. Kakade
Thomas Jefferson University
Department of Surgery
Division of Colorectal Surgery
Philadelphia, PA 19107
Gerald A. Isenberg, MD, FACS
Thomas Jefferson University
Department of Surgery
Division of Colorectal Surgery
Philadelphia, PA 19107
Correspondence
Dr. Gerald Isenberg
Department of Surgery
1015 Walnut Street
Curtis Building, Suite 620
Philadelphia, PA 19107
Phone: 215-955-8643
E-mail: Gerald.Isenberg@jefferson.edu
Disclosures
The authors have no conflicts of interest to disclose.
References
- Begos DG, Sandor A, Modlin IM. The diagnosis and management of adult intussusception. Am J Surg. 1997;173:88-94.
- Azar T, Berger DL. Adult intussusception. Ann Surg. 1997;226:134-138.
- Onkendi EO, Grotz TE, Murray JA, et al. Adult intussusception in the last 25 years of modern imaging: is surgery still indicated? J Gastrointest Surg. 2011;15:1699-1705.
- Sanders GB, Hagan WH, Kinnaird DW. Adult intussusception and carcinoma of the colon. Ann Surg. 1958;147:796-804.
- Siddiqui AA, Glynn C, Harford WV, et al. Cecoanal intussusception in an adult caused by cecal polyp. South Med J. 2009;102:446-447.
- Ohno M, Nakamura T, Hori H, et al. Appendiceal intussusception induced by tubulovillous adenoma with carcinoma in situ: report of a case. Surg Today. 2000;30:441-444.
